H.I.V. = human immunodeficiency virus. Probably
leads to AIDS, although the timescale is variable, and depends upon numerous factors,
including: treatment regimes; infections to which the person is
exposed. Essentially, HIV attacks and disables a group of cells in the immune system, the
CD4 cells. These are necessary for defending the person against cell mediated
infections (eg. TB).

A.I.D.S. = acquired immune deficiency syndrome. A term used to describe the
presence of specific infections that indicate end stage immune system breakdown. The
onset of AIDS is manifested by the appearance of 2 major opportunistic infections:
Kaposis sarcoma, pneumocystis carinii pneumonia (P.C.P.) - see the section below for
more information on the virology of HIV.

Words/phrases anomalous or now out of vogue:

full blown AIDS - seen as too condemning and unspecific

ARC (AIDS related complex) - recently, it has been shown that this is NOT always
AIDS related (i.e. progression to the onset of major infections does not always occur) -
also, too condemning

you can catch AIDS. - common in the media, this phrase is flawed due
to the fact that AIDS is a syndrome caused by the HIV, which is the only thing that can be
caught

people with the HIV are dying - this is patently not true
- neither have they got AIDS. They do have within them a virus that (on
current information) will eventually attack a specific part of their immune system
- current treatments in the developing world are extending the lives of
people with HIV significantly

AIDS is a gay plague - in the West, HIV and AIDS first appeared in
the gay and drug using communities, but taken globally, the main route of transmission has
always been via a heterosexual route

examples of misleading or salacious headlines: normal sex is safe; AIDS is a
punishment from God; people with the HIV have themselves to blame; kissing will give you
AIDS; AIDS horror on QE2; school walkout - demo as AIDS child starts school; sex with
monkeys - AIDS threat; AIDS is the natural consequence of a permissive society etc.

1.2 - History

Everybody knows that pestilences have a way of recurring in the world; yet
somehow we find it hard to believe in ones that crash down on our heads from a blue sky.
There have been many plagues and wars in history; yet always plagues and wars take people
equally by surprise. (Camus, 1971, p 34).

The last major world wide epidemic was in 1918/1919, when an influenza virus killed 20m
people, and large numbers of brain damaged survivors were left.

The African Connection - The source of HIV is a topic of hot debate. It is
now thought that HIV lived for many years (along with other apocolyptic
viruses such as Ebola and Lassa) in central Africa in a pre-epidemic state (Anderson and
May, 1992; Wills, 1997). Factors that precipitated the current epidemic include: military
and civil unrest in many African states; shifting national borders as a result; economic
exploitation; increasing international travel (see Wills, 1997, for more detail).

The dangers of this thesis are obvious: dangers of inciting racism; the
definition of AIDS in Africa is not clear [in the absence of expensive tests, many
manifestations of TB mimic the symptoms of AIDS]. As mentioned above, the mode of
transmission in Africa is predominantly heterosexual, perhaps connected with the high
incidence of untreated sexually transmitted diseases (STDs), especially syphilis and
gonorrhea. These often manifest as open sores, providing an ideal route for HIV
transmission.

Timetable of events:

1954 - currently, the earliest date that a person is thought to have died of an
AIDS type syndrome. The victim was a young rent-boy in New York.

1959 - the earliest that a person in the UK is thought to have had the virus - a
sailor from Manchester.

1981 - 20 cases of Kaposis sarcoma appeared in young men NOT of middle
eastern origin (where the condition is more common). The individuals were found to have
damaged immune-systems.

Also, other (homosexual) young men were found to have acquired unusual fungal and
parasitic infections. Initially, this led the (US) authorities to cite the appearance of a
gay plague. However, once the tumours and other infections appeared in
heterosexual drug users and spouses/sexual partners of people with AIDS, the virus was
seen not to be confined to just one group.

1983 - The Pasteur institute in Paris isolated a virus in the lymph glands of an
individual thought to have the new virus - they called the virus
lymphadenopathy associated virus (LAV).

1984 - Robert Gallo in the USA isolated a retrovirus and antibodies that matched a
virus in people with AIDS - HIV had been finally discovered.

NB. Montagnier of the Pasteur institute and Gallo were, until recently, hauling each
other through the courts, each battling to be recognised as the discoverer of the
HIV.

World - approx. 33.3m people in the world are living with HIV. See the
UNAIDS site for
more information

In the UK, 60% of HIV diagnoses are from homosexual or bisexual men. Heterosexual
intercourse accounts for 19% of HIV. Other routes (intravenous drug use, mother to child
transmission, etc.) account for the remainder.

1.4 - A brief virology of HIV

The immune system is essentially composed of three branches, each of which has a
specific role in defending the body against bacterial and viral attack: the non-specific
branch (e.g. ear wax, gastric acid, saliva); the cell-mediated branch (using various types
of T cells to attack organisms that enter cells); the humoral branch (based on
the action of antibodies).

HIV attacks and invades cells within the cell mediated branch of the immune
system - specifically the CD4 (or T4) cells. Their task is to switch on that
branch of the system. HIV is a retrovirus - that is, information the virus holds
about itself is stored in the form of RNA (ribonucleic ac id), as opposed to DNA
(deoxyribonucleic acid). Once inside the T4 cell, the HIV takes on the DNA configuration
of the host, and is then replicated within the cell, and also whenever the body demands
more CD4 cells (see diagram below).

All effected CD4 cells are inactivated once invaded, and the person becomes more open
to infections such as: candida (thrush); T B; certain cancers; toxoplasmosis;
cytomegalovirus (CMV) that can cause blindness; cryptosporidiosis (leading to severe
diarrhoea and weight loss). Due to some crossover between the cell-mediated immune system
and the humoral based (antibody) immune system, the latter is also (eventually) affected.
In addition, there are similar cells within the nervous system, and therefore people with
the HIV are likely to develop neurological complications as well (memory loss, slurring of
speech, and encephalitis).

As the number of effective CD4 cells declines, the person becomes more prone to
opportunistic infections, and the number of active CD4 cells is often taken as a marker as
to when anti-viral treatment should be commenced.

2. Modes of Transmission

As with the transmission of any organism, there are 3 important elements to consider -
the quantity, the quality, and the route of transmission. With the HIV, there are 5
specific routes through which the virus can be spread:-

Transfusion of blood and blood products - this includes via blood transfusion (rare in
the UK)

Use of infected donor organs, tissue or semen

Mother to baby - 17% - 30% of babies born to HIV + ve mother will themselves become
infected (although this can only be established after a certain time)

Unprotected penetrative vaginal or anal intercourse - especially from male to
female (vaginal, sex), and male to passive male/female (anal sex) -risky
behaviour is not so much a ranking as a point on a continuum - at one end there is blood
transfusion; needle swapping; anal intercourse) ranging over to less violent
activities (rimming; heterosexual sex) - cuddly vs. violent sex?

3. Stages of infection

Initially, there will be a short period of feeling unwell and experiencing flu
like symptoms. There may be a slight rash, and swelling of the lymph nodes in the groin,
armpits and neck. In this first period, the person is extremely infectious. At this stage
(up to 3 months), an HIV test will show negative - the HIV test is specifically
designed to look for antibodies against HIV [looking for the virus bodies themselves are
expensive and the test inaccurate].

Therefore, a negative test does not mean the person is infection free, unless
there is an absolute guarantee that the individual has not been exposed to the virus
within the previous 3 - 6 months.

There then follows a time when the person is symptomless. The timescale between
infection and the onset of minor opportunistic infections such as thrush, general malaise,
persistent generalised lymphadenopathy (PGL), meningitis (rare) is variable - in the
elderly, it is much shorter (sometime 6 months) than in others (currently up to
19 years). Certain
precipitating factors can hurry the preaches, e.g. pregnancy, and age (the elderly have a
weaker immune system due to the ageing process.

Once the number of CD4 cells in the cell-mediated immune system begin to fall, there
will be an increase in the number of minor opportunistic infections, as well as the more
serious, specific infections that are used to diagnose the onset of AIDS (not
now referred to an full blown).

4. The nurses role

4.1 - Universal Precautions

Universal precautions assume that anybody is potentially a carrier of a blood borne
virus - and therefore all people in hospital are treated identically. They apply whenever
contact with blood, semen, cerebro-spinal fluid [usually from around the spinal cord],
vaginal secretions, pericardial fluid [from around the heart] or amniotic fluid.

Initially, an appropriate risk assessment should be carried out. Then,
precautions can be taken which could entail any of the following:

if in doubt regarding spillages etc., contact the domestic supervisor

if its wet and sticky, use a barrier [applies to many situations!]

Information from the Department of Health indicates that HIV can survive within
a cadaver for up to 16 days following death, and for up to 2 months in blood kept at room
temperature.

The Department of Health (1997) has recently published guidelines for the action
required if a health care worker is exposed to HIV - this includes commencing anti-viral
treatment immediately, and it is recommended all centres have a pack available for
immediate use.

4.2 - Attitudes and prejudice

The unsafe behaviour that produces AIDS is judged to be more than just weakness - it is
indulgence, delinquency - addictions to chemicals that are illegal and sex regarded as
deviant (Sontag, 1991).

There is much research that identifies nurses as being significantly prejudiced against
people with the HIV, or who are deemed to be at risk [see reference list 3]. For example,
Akinsanya (1992) found that: 13% of staff thought there was a risk from sharing crockery
with an infected individual; 23% felt that people with AIDS should be nursed in isolation
from other patients; 27% agreed that all people should be tested for HIV on admission to
hospital; 32% were concerned about infection from donating blood.

Much of the prejudice is based on: a flawed knowledge base; a fear of catching the
virus though accidental injury; inherited/personal value system. Significantly, 75% of one
sample stated that the health care worker should be aware of the diagnosis (Burtis and
Evangelista, 1992).

The risk of acquiring the virus is small (as compared to hepatitis B). One paper
(Marcus, 1988) surveyed 1201 health care workers in the USA exposed to HIV +ve blood. Four
(4) seroconverted (ie became HIV +ve themselves). Two were exposed during resuscitation,
and 1 from recapping a needle. 37% of the 1201 initially exposed to the virus could have
prevented the incident. Vlahov and Polk (1987) stated that, following a needlestick
injury, there is a 6-30% chance of acquiring hepatitis B, and a <1% chance of
contracting HIV.

Ethically, and professionally, nurses cannot refuse to care for a person with the HIV
or AIDS. Only in specific cases can individual cases be addressed - for example, it may be
wise not to expose a pregnant nurse to toxoplasmosisis.

Like syphilis in the 1900s, AIDS has brought into play the attribution of moral meaning
to biological phenomena (Brandt, 1988).

Closing comments:

HIV has successfully established itself in all layers of human strata: health care
workers and carers would be wise to consider HIV not as an infection confined to any
particular social group, but to all the ages of man described by Shakespeare
in As You Like it - from the infant mewing and puking in his mothers arms,
through to second childishness and mere oblivion..sans teeth..sans everything (II,
7). As the world enters the third millenium, HIV, along with TB and enteric disease, will
present health promotion and medicine with a continuing challenge.

Recommended Sources [1]

General texts and articles

(core sources in bold)

Advisory Committee on Dangerous Pathogens (1996) - Protection against blood borne
infections in the workplace: HIV and hepatitis. The Stationary Office, London

Wills, R. (1997) - Plagues: Their Origin, History and Future. Flamingo, London
-overview of plagues from prehistory to the present. Good chapter on HIV, and much
useful information about other conditions, including syphilis. Very readable.

Department of Health (1992) - The Health of the Nation. HMSO, London - target
area for HIV and AIDS is interesting, but flawed due to the emphasis on behaviour alone,
and use of other STDs as markers for HIV

Moore, O. (1996) - PWA: Looking AIDS in the Face. Picador, London
- excellent
and moving book, compiled from the 'GuardianŽarticles published over the 2 years before
Oscar died of an AIDS related illness

Shilts, R (1987) - And the Band Played on. Penguin, London - an American
writers perception of the political and social intransigence that contributed
towards the spread of the HIV

Watney, S (1987) - Policing Desire: pornography, AIDS and the media. Methueu,
London - main thesis is that the moral majority among the conservative party used the
HIV to marginalise groups that did not fit with their view of normal'

RECOMMENDED SOURCES [3]

Attitudes of health care workers to

people with HIV and AIDS

(core sources in bold)

Akinsanya, J. & Rouse, P. (1992) - Who will care ?: A survey of the knowledge and
attitudes of hospital nurses to people with HIV and AIDS. Journal of Advanced Nursing,
17 (3) pp 1068-1077

Snowden, L. (1997) - An investigation into whether nursing students alter their
attitudes and knowledge levels regarding HIV infection following a 3 year programme
leading to registration as a qualified nurse. Journal of Advanced Nursing, 25, pp
1167 - 1174